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What will the new DSM-5 mean for us Brits?

There was a slightly provocative headline to this Guardian article a couple of days ago. “Asperger’s syndrome dropped from psychiatrists’ handbook the DSM”. This refers to the DSM-5, the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, which will be published by the American Psychiatric Association. Though actually Asperger’s isn’t so much being “dropped” as merged into one catch-all diagnosis of Autistic Spectrum Disorder.

This left me wondering about how the new DSM will affect mental health services over here.

I suspect it initially won’t affect us a great deal in Blighty. Psychiatrists in the UK usually base their diagnostic categories on the World Health Organisation’s ICD-10 rather than the American DSM. Also it’s important to note that diagnostic categories are not the only thing that affects what mental health services will or won’t do. There may be a diagnosis listed for, say, “oppositional defiant disorder” in the DSM and ICD-10, but my Child and Adolescent Mental Health Service doesn’t accept referrals for it. Such problems are considered the realm of school strategies, parent training and youth offending services, not child psychiatry. Those who say that psychiatry is out to medicalise all forms of human behaviour can take comfort that in our corner we wouldn’t be able to do that even if we wanted to. We don’t have the time or resources.

But it is true that what happens in America has a tendency to filter down to the rest of us, though not always. Pediatric bipolar disorder, for example, never really took off outside the United States.

I’m in two minds about the idea of merging Asperger’s into ASD. On one level I can see a rationale for it. It’s really not clear that Aspergers is a distinct condition from ASD. I also can’t think of anything that we do differently as a result of saying that a child has Asperger’s rather than ASD.

On another level, I wonder what effect this might have on the neurodiversity community and the sense of identity that some people have fostered. Also, I’m slightly concerned about the effect this might have, given that we’re referring to a condition that causes people to have difficulty coping with change.

This article on NHS Choices gives a few of the other changes. A new category coming in is “disruptive mood dysregulation disorder”; basically an angry child. The rationale given is an eyebrow-raising one, “to address concerns about potential over diagnoses and overtreatment of bipolar disorder in children”. In other words, the whole fad for pediatric bipolar disorder got so out of control Stateside that they had to create a diagnostic category to accept that some children get angry a lot. By comparison, I’ve been in CAMHS for five years and I’ve never met a pre-pubescent child with a diagnosis of bipolar disorder. Neuroskeptic has an excellent critique here, in which he points out that it basically describes the same thing as oppositional defiant disorder.

There’s also some diagnoses going into the DSM-5 under the category of “conditions that require further research before their consideration as formal disorders.” Such as “internet use gaming disorder.” Here’s a musical number from some precontemplative addicts.

I doubt we’d be accepting referrals for that either, other than to write back suggesting the parents unplug the X-Box for a while.

There’s also some proposed categories that aren’t going to make it into the DSM-5, such as:

parental alienation syndrome – a term proposed to describe a child who ‘on an ongoing basis, belittles and insults one parent without justification’

Fair enough, because including that would be really silly.

There’s probably a lot more to be said about the DSM-5, particularly about the new dimensional approach to assessing personality disorders, but I’ve limited myself here to discussing it from a CAMHS perspective.